﻿<!DOCTYPE html>

<html lang="en" xmlns="http://www.w3.org/1999/xhtml">

<head>
    <meta charset="utf-8" />
    <title></title>
    <style type="text/css">
        * {
            margin: 0;
            padding: 0;
            font-size: 14px;
        }

        .wrapBox {
            width: 95%;
            margin: 0 auto;
        }

        body {
            font-family: SimSun !important;
            padding-top: 5px;
            padding-bottom: 10px;
        }

        p {
            margin: 0px;
            line-height: 180%;
        }

        footer {
            color: #333;
            font-size: 1rem;
            margin-bottom: 1.5rem;
            margin-right: 5%;
            margin-top: 1.2rem;
            text-align: right;
        }

        table,
        td {
            border: 1px solid #444;
            border-collapse: collapse;
            /* text-align: center; */
            height: 3rem;
        }

        .classItem {
            overflow: hidden;
            width: 100%;
        }

        .classItem .itemLeft {
            float: left;
            width: 50%;
        }

        .classItem .itemCont {
            width: 50%;
            float: left;
            text-align: left;
        }

        .classItem .itemCont .lag {
            font-size: 16px;
        }

        .classItem .itemCont strong {
            display: block;
        }

        .classItem .itemInput {
            border: 2px solid;
            background: #F1F4FF;
            height: 50px;
            line-height: 50px;
            margin-bottom: 5px;
            width: 80%;
            float: right;
        }

        .classItem .itemInput label {
            width: 130px;
            font-size: 16px;
            background: #fff;
            font-weight: bold;
            text-align: center;
            display: block;
        }

        /* .classItem .itemInput label::before {
            content: '';
            height: 0;
            width: 10px;
            height: 10px;
            border: 1px solid;
            text-align: center;
            margin: 19px 0 -17px -16px;
        }

        .classItem .itemInput.cur label::before {
            background: #444;
        } */


        table td {
            color: #000;
            font-size: 14px;
        }

        table .item2 {
            background: #B8CCE4;
            color: #000;
            font-size: 14px;
        }

        table .custStyle {
            background: #DCE6F1;
            color: #000;
            font-size: 14px;
        }

        table .mystyle {
            color: #000;
            font-size: 14px;
        }

        table .mystyle span {
            margin-left: 20px;
        }
    </style>
</head>

<body>
    <div class="wrapBox">
        <div class="classItem">
            <div class="itemLeft" style="width: 60%;">
                <div style="overflow:hidden">
                    <div class="itemCont" style="width: 40%;">
                        <img src=""
                            alt="" width="160"  style="margin-top: 20px;" />
                        
                    </div>
                    <div class="itemCont" style="width: 60%;">
                        <h1 style="font-size: 24px;">COWAY USA, INC.</h1>
                        <p> 4221 WILSHIRE BLVD #210, LOS ANGELES, CA 90010</p>
                        <p class="lag">TEL : 213-386-3033, FAX : 323-549-0910 billing@coway-usa.com</p>
                    </div>
                </div>
            </div>
        </div>

        <table style=" width: 100%;">
            <tr style="font-size: 1rem; background-color:#366092">
                <td style="text-align: center; color: #fff;" colspan="11">CREDIT CARD PAYMENT AUTHORIZATION FORM</td>
            </tr>
            <tr>
                <td colspan="12" class="mystyle" style="text-align: center;">
                    <span>VISA</span>
                    <span>MASTER </span>
                    <span>DISCOVER</span>
                </td>
            </tr>
            <tr>
                <td class="item2" style="width:200px">CARD #</td>
                <td colspan="10" class="mystyle">

                </td>
            </tr>
            <tr>
                <td class="item2" style="width:200px">CVV #</td>
                <td colspan="10" class="mystyle">

                </td>
            </tr>
            <tr>
                <td class="item2" style="width:200px">CARD HOLDER NAME</td>
                <td colspan="10" class="mystyle">

                </td>
            </tr>
            <tr>
                <td class="item2" style="width:200px">ORDER #</td>
                <td colspan="10" class="mystyle">

                </td>
            </tr>
            <tr>
                <td class="item2" style="width:200px">BILLING ADDRESS</td>
                <td colspan="10" class="mystyle">

                </td>
            </tr>
            <tr>
                <td class="item2" style="width:200px">ZIP CODE</td>
                <td colspan="10" class="mystyle">

                </td>
            </tr>
            <tr>
                <td class="item2" style="width:200px">REMARK</td>
                <td colspan="10" class="mystyle">

                </td>
            </tr>
            <tr>
                <td colspan="12" class="mystyle">
                    <p style="padding-left:5%">SIGNATURE OF CARD HOLDER</p>
                    <p style="padding-left:5%">DATE</p>
                    <p style="padding-left:5%">CONTACT #</p>
                    <p style="padding-left:5%">RECEIVER</p>
                </td>
            </tr>
            
            <tr style="visibility:hidden;">
                <td style="height: 0; " width="200px"></td>
                <td style="height: 0; " width="75px"></td>
                <td style="height: 0; " width="225px"></td>
                <td style="height: 0; " width="75px"></td>
                <td style="height: 0; " width="125px"></td>
                <td style="height: 0; " width="75px"></td>
                <td style="height: 0; " width="25px"></td>
                <td style="height: 0; " width="25px"></td>
                <td style="height: 0; " width="75px"></td>
                <td style="height: 0; " width="25px"></td>
                <td style="height: 0; " width="125px"></td>
            </tr>
        </table>
    </div>

</body>

</html>

<style>
    .SIGNATURE p {
        overflow: hidden;
        margin: 10px;
    }

    .SIGNATURE label {
        color: #000;
        display: inline-block;
        width: 200px;
        text-align: left;
        float: left;
        font-size: 14px;
    }
</style>